Post Traumatic Stress Disorder (PTSD) consists of three main symptom clusters: (1) re-experiencing the trauma in the present moment, (2) avoidance of reminders associated with the trauma, and (3) a persistent sense of current threat, manifested through exaggerated startle responses and hypervigilance (Karatzias et al., 2017).
Complex PTSD (CPTSD) encompasses the three PTSD clusters along with three additional clusters that indicate disturbances in self-organization: (1) affective dysregulation, (2) negative self-concept, and (3) disturbances in relationships, as defined by the International Classification of Diseases, 11th revision (ICD-11; Harrison et al., 2021).
While physical exercise is widely recognised for its mental health benefits (e.g., Chekroud et al., 2018), its role in treating PTSD and complex PTSD remains underexplored. Biernacka et al. (2024) aimed to achieve the following research objectives:
- To explore trauma clinicians’ perspectives on the role of physical exercise in the treatment of PTSD and CPTSD.
- To understand trauma clinicians’ perceptions of the key barriers and facilitators that affect their recommendations of physical exercise as a supportive treatment for PTSD and CPTSD.
Research to date on physical exercise as a supportive intervention for PTSD and CPTSD remains limited, and it often neglects clinicians’ perspectives.
Methods
The study involved semi-structured interviews with qualified mental health professionals in the UK who specialise in treating PTSD and CPTSD in outpatient trauma services. These tertiary-level services employ experienced psychological therapists who collaborate with clients on treatment decisions.
The interview guide was developed by the research team based on the study’s questions. It began with questions about clinical work and included participants’ views on recommending physical exercise for PTSD/CPTSD, along with perceived barriers and facilitators (e.g., What do you think could facilitate the use of physical exercise as an adjunctive treatment for PTSD/CPTSD?).
Participants were recruited using purposive and snowball sampling techniques. The authors initially contacted potential participants through professional trauma networks and social media. Interested clinicians were then followed-up, and those who decided to participate provided a written informed consent and completed a sociodemographic form sharing information about their gender, age, ethnic background, occupation, workplace, and UK region. Interviews were conducted remotely and recordings were transcribed verbatim, removing any identifying information. Pseudonyms were used in the results to protect people’s anonymity.
Reflexive thematic analysis (Braun & Clarke, 2006) was employed to analyse the data, capturing a range of opinions that could inform future practice and research. Reflexivity was ensured within team discussions, and authors’ beliefs and assumptions were discussed to reduce bias. The diverse personal and professional experiences of the research team enhanced the study’s depth. The authors adopted a critical realist stance aligned with reflexive thematic analysis principles. Lastly, the researchers followed the Standards for Reporting Qualitative Research (SRQR; O’Brien et al., 2014) and ensuring trustworthiness through discussions with clinical peers and participant validation of preliminary findings.
Results
The study included 12 participants, the majority of whom were female (75%). Participants’ ages spanned several decades, with equal representation from the 30–39, 40–49, and 50–59 age groups, each accounting for 25% of the sample. A smaller proportion were under 30 (16.7%), and only one participant (8.3%) was 60 or older. All participants identified as White (100%). Regarding professional roles, most were Clinical Psychologists (75%), while the rest were evenly distributed among Counselling Psychologists, Counsellors/Psychotherapists, and CBT Therapists, each representing 8.3% of the sample.
Participants worked in various settings: half (50%) were employed in the National Health Service (NHS), 25% in private practice, and 16.7% at universities. One participant (8.3%) worked in both the NHS and private practice. Participants were primarily based in London (41.7%), with smaller representations from the South East (16.7%), South Central (16.7%), and South West (16.7%) regions of the UK. Only one participant (8.3%) was located outside of these regions nationally.
Three main themes concerning clinicians’ perspectives on incorporating physical exercise into the treatment of PTSD and CPTSD were identified: the potential benefits of physical exercise, the barriers to including physical exercise, and the importance of individualised care that underlies both the benefits and barriers.
Potential benefits of physical exercise
All participants recognised the value of physical exercise. However, there were variations in how they perceived its importance and implemented it in treatment. Many clinicians emphasised exercise as a crucial part of recovery for trauma-affected individuals. While some saw it as general health advice, others integrated it deliberately into therapy, recognising its ability to support both the mind and body. Exercise was often incorporated into sessions as part of a holistic approach to treating trauma, bridging psychological and physiological well-being. For some clients, physical exercise became a means to rebuild their lives. Activities such as yoga, running, and walking were described as vehicles for reclaiming autonomy and confidence.
So, there’s the physical exercise part, but is it the intrinsic physical exercise that’s the important bit or is it all the stuff that comes around it, like the social structures or the things like people doing park run.
Clinicians found that physical exercise was helpful for clients in reducing symptoms of hyper-arousal and hyper-vigilance, as well as managing anxiety.
I also felt it would help him with that constant shaky sense of being vigilant and on guard. So, it would help to make that anxiety lower.
Several clinicians indicated that they intentionally use physical exercise for its potential benefits in processing trauma memories. They believe that certain types of exercise that engage both sides of the body may be particularly beneficial, as they can mimic the processes involved in Eye Movement Desensitization and Reprocessing (EMDR).
It also fits alongside for me something of EMDR, as well. So, moving or running, it’s about bilateral stimulation, so you are activating the left and right-hand sides. (…) so walking is good for that kind of movement that activates bilateral stimulation.
Barriers
Clinicians identified several barriers that hinder the integration of physical exercise in trauma treatment. These challenges were grouped into environmental, client, clinician, and service-related barriers.
Clinicians emphasised that socio-economic factors significantly impact clients’ ability to engage in exercise. Vulnerable clients often lack resources like gym memberships or proper running shoes. The limited availability of programs, such as “exercise on prescription” further compounded this issue, with many clinicians unsure about its current status.
[vulnerable clients] don’t have those resources and feel isolated. They are the ones that need this. But we need funding. You need the funding, for the support workers, the kind of safe spaces in the gym, for training people in the gym or outdoors or, you know, wherever it is, having a range of different approaches, and different things for different ages.
The lack of trauma-informed and culturally appropriate exercise spaces posed another challenge. Gyms and swimming pools were often perceived as intimidating, especially for abuse survivors. Clinicians described how such environments could be loud, predominantly male, and triggering for clients.
There is something quite challenging about being, say, in a swimming pool or a gym environment, you know, there is a lot, for women, there is a lot of men around, your body is quite on display, and I think that for people who have been abused, of it there is like permanent scarring, things like that, I think that can be quite a challenge.
Cultural considerations were equally important. For example, clients with language barriers might struggle to communicate specific needs, such as exercise adaptations for physical limitations, to instructors.
In regard to client-driven factors, clients often faced severe anxiety about leaving their homes, making outdoor exercise inaccessible. While home-based workouts offered an alternative, space constraints in small homes further limited this option. Exercise itself could be triggering. Natural physical sensations such as laboured breathing could remind clients of their trauma. However, clinicians noted that these triggers presented opportunities for therapeutic desensitisation.
…many of my clients avoid leaving the house completely, just because they are so anxious about being triggered by things like noises, airplanes, certain smells, (…) if you think of exercise, you might be thinking to leave the house. Obviously, you can do work at home, but if your house is quite small, you’re quite limited, aren’t you?
Physical conditions, such as chronic pain, were significant barriers to exercise. While clinicians acknowledged that even minimal activity could be beneficial, they stressed the need for managed expectations.
Many clients’ comorbid depression severely diminished their motivation to exercise. Clinicians described this as a “chicken and egg” situation, where clients’ lack of motivation could be addressed by exercise, but getting started was an obstacle in itself. Clients often struggled to see the value in exercise, particularly if they had no prior experience of its benefits or felt disconnected from previous athletic abilities. Feelings of shame, particularly among clients with CPTSD, further hindered their engagement in self-care, including exercise.
Lastly, some clients deprioritised exercise due to past struggles to meet basic needs like food and shelter.
Furthermore, many clinician and service-level barriers were identified. Several clinicians admitted that exercise was often overlooked in trauma treatment. Some participants reflected that the interviews themselves were the first time they had considered exercise as part of treatment. Clinicians expressed frustration with the limited emphasis on exercise within their profession. Some clinicians felt unprepared to recommend exercise safely, particularly for clients with physical health issues.
I think sometimes it can feel a bit deskilled in terms of knowing how much to push. In line with that, you don’t want to exacerbate a physical condition, but at the same time, we know that a lot of things like chronic pain, fibromyalgia, any … like some kind of pace activity is actually more beneficial, but I guess it’s not necessarily having the knowledge to know how much to push that.
Participants highlighted the need for multidisciplinary teams, including personal trainers or occupational therapists, to bridge this gap. Clinicians also emphasised the need for more accessible evidence, guidelines, and resources to confidently recommend exercise.
Clinicians found exercise to be beneficial in trauma treatment, however some notable barriers included lack of clinical confidence and training to incorporate physical exercise in psychotherapy.
Conclusions
This study highlights the potential of physical exercise as a valuable component in the treatment of PTSD and complex PTSD, while emphasising the importance of addressing systemic barriers to its implementation. By exploring trauma clinicians’ perspectives, it provides key insights for integrating exercise into trauma care and advancing more comprehensive, patient-centred treatment approaches.
The findings underline the importance of developing personalised approaches to integrate physical exercise into trauma therapy while addressing existing service gaps.
Strengths and limitations
The study provides valuable insights into trauma clinicians’ perspectives on incorporating physical exercise into the treatment of PTSD and complex PTSD. It addresses an important gap in understanding non-traditional therapeutic approaches. A major strength of the research is its focus on a topic that is often overlooked in trauma therapy, which has the potential to enhance evidence-based practice. The qualitative design enables an in-depth exploration of clinicians’ experiences, yielding nuanced findings that could help inform tailored interventions. The inclusion of a diverse group of clinicians adds depth to the data, offering a broader perspective on the challenges and facilitators associated with integrating exercise into trauma treatment.
The paper holds clinical significance, highlighting the potential benefits of exercise in improving outcomes for PTSD and CPTSD patients. Its relevance is heightened by the growing interest in holistic mental health interventions. The findings advocate for further exploration into how exercise can complement traditional therapies, potentially expanding treatment options for individuals with trauma-related disorders.
However, the study does have limitations. While the sample size is adequate for qualitative research, it may not fully represent the views of trauma clinicians across various contexts and healthcare systems. The sample reflects diversity in professional roles and settings, but it is less diverse in terms of ethnicity and geography.
Although the findings highlight barriers such as resource constraints and lack of training, the study does not provide detailed solutions or actionable recommendations for overcoming these challenges. Future research could address these gaps by exploring perspectives from a more diverse sample and testing practical strategies for integrating exercise into trauma care.
The study underscores the promise of exercise in trauma therapy while revealing gaps in diversity and actionable strategies.
Implications for practice
Integrating physical exercise into the treatment of PTSD and CPTSD holds promise for improving patient outcomes, but certain practical challenges must be addressed. Clinicians should consider including physical activity as a complement to traditional therapies, customising approaches to meet the individual needs and preferences of each patient. To implement this effectively, training programs should equip clinicians with the skills necessary to integrate exercise into treatment plans and to address potential barriers, such as limitations in resources and patient readiness.
Service providers should develop accessible, trauma-informed exercise programs in collaboration with fitness professionals to ensure safety and inclusivity. Group-based exercise initiatives may also promote social support, which can be beneficial for trauma survivors. Policymakers and healthcare leaders should invest in resources to expand access to these programs, especially in underserved areas.
Finally, more efforts are needed to diversify research and practice by including perspectives from a broader range of clinicians and patients across different cultural and geographic contexts. This approach can reveal culturally specific barriers and facilitators, leading to more equitable implementation of exercise-based interventions.
Harnessing the therapeutic potential of physical exercise requires tailored approaches, clinician training, and inclusive program design.
Statement of interests
No conflicts of interest to declare.
Links
Primary paper
Biernacka, N., Talwar, S., & Billings, J. (2024). Trauma clinicians’ views of physical exercise as part of PTSD and complex PTSD treatment: A qualitative study. PLOS Mental Health, 1(4), e0000114.
Other references
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), 77-101.
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Harrison, J. E., Weber, S., Jakob, R., & Chute, C. G. (2021). ICD-11: an international classification of diseases for the twenty-first century. BMC medical informatics and decision making, 21, 1-10.
Karatzias, T., Cloitre, M., Maercker, A., Kazlauskas, E., Shevlin, M., Hyland, P., … & Brewin, C. R. (2017). PTSD and Complex PTSD: ICD-11 updates on concept and measurement in the UK, USA, Germany and Lithuania. European journal of psychotraumatology, 8(sup7), 1418103.
O’Brien, B. C., Harris, I. B., Beckman, T. J., Reed, D. A., & Cook, D. A. (2014). Standards for reporting qualitative research: a synthesis of recommendations. Academic medicine, 89(9), 1245-1251.
